Do you live within 1 hour of Austin, Texas?*

YesNo

Are you at least 18 years of age or older?*

YesNo

Are you willing to provide information related to current and past mental health diagnoses, and current and past psychiatric medications?*

YesNo

Do you have a current diagnosis of epilepsy and/or other current seizure disorders?*

YesNo

Do you have compromised facial neuro-ophthalmic integrity (visual symptoms resulting from brain diseases) due to stroke, MS, ALS, or other neurological conditions?*

YesNo

Do you currently have any eye conditions which impair your ability to see (even with corrective lenses) or recent surgeries or trauma to your eye?*

YesNo

Have you experienced a Traumatic Brain Injury (TBI) within the last 12 months?*

YesNo

Are you pregnant or intending on becoming pregnant in the next few months?*

YesNo

Have you participated in a Senseye study before?*

YesNo

Sometimes things happen to people that are unusually or especially frightening, horrible, or traumatic. For example:

• A serious accident or fire

• A physical or sexual assault or abuse

• An earthquake or flood

• A war

• Seeing someone be killed or seriously injured having a loved one die through homicide or suicide.

Have you ever experienced this kind of event?*

Yesno

In the past month, have you...

Had nightmares about the event(s) or thought about the event(s) when you did not want to?*

YesNo

Tried hard not to think about the event(s) or went out of your way to avoid situations that reminded you of the event(s)?*

YesNo

Been constantly on guard, watchful, or easily startled?*

YesNo

Felt numb or detached from people, activities, or your surroundings?*

YesNo

Felt guilty or unable to stop blaming yourself or others for the event(s) or any problems the event(s) may have caused?*

YesNo

Your Name*

Phone Number*

Your email*